CNS infections

Question 1

what is initial empirical therapy of meningitis if meningococcal disease (meningitis with non blanching rash or meningococcal septicaemia) is suspected

Answer 1

give single dose of benzylpenicillin before hospital if this does not delay transfer

Question 2

what is initial empirical therapy for suspected bacterial meningitis without non blanching rash (plus alternatives)

Answer 2

if can’t be transferred to hospital urgently, give benzylpencillin before transfer
alternative in allergy: cefotaxime
if history of immediate hypersensitivity to penicillin or cephalosporins: chloramphenicol

Question 3

in hospital, consider adjunct treatment of meningitis with…

Answer 3

dexamethasone
esp if pnuemococcal meningitis suspected in adults
preferably start before or with first dose of abx, but no later than 12h after starting abx

Question 4

when giving dexamethasone, preferably start before or with first dose of abx, but no later than …. after starting abx

Answer 4

12 Hours

Question 5

in hospital consider adjunct treatment with dexamethasone esp if ….

Answer 5

pneumococcal meningitis suspected in adults

Question 6

avoid dexamethasone is the following (4)

Answer 6

• septic shock
• meningococcal septicaemia
• immunocompromised
• meningitis following surgery

Question 7

in hospital, if aetiology is unknown as the pt is ages 3 months to 49 years, give the following (and also when to consider adding vancomycin, and also how long treatment for)

Answer 7

• cefotaxime (or ceftriaxone)
• consider adding vancomycin if prolonged or multiple use of abx in the last 3 months, or if travelled to areas outside UK with highly penicillin and cephalosporin resistant pneumococci in the last 3 months
• suggested duration 10 days

Question 8

in hospital, if aetiology is unknown and the pt is 60 and over give (and when to consider adding vancmycin and duration of treatment)

Answer 8

cefotaxime (or ceftriaxone) + amox (or ampicillin)
consider adding vancomycin if prolonged or multiple use of abx in last 3 months, or if travelled to areas outside UK with highly penicillin and cephalosporin resistant pneumococci in last 3 months
suggested duration treatment 10 days

Question 9

treatment and duration for meningitis caused by meningococci (+ if hypersensitivity)

Answer 9

benzylpenicillin sodium or cefotaxime (or ceftriaxone) for 7 days
if history of immediate sensitivity to penicillin or cephalosporin chloramphenicol for 7 days

Question 10

meningitis caused by pneumococci - treatment
(plus adjunct with dexamethasone, plus if microorganisms are penicillin sensitive plus if highly penicillin and cephalosporin resistant plus duration of treatment)

Answer 10

• cefotaxime (or ceftriaxone)
• consider adjunctive treatment with dexamethasone, preferably before or with first dose of abx, but no later than 12h after starting abx
• this may reduce penetration of vancomycin in CSF
• if microorganisms are penicillin sensitive, replace cefotaxime with benzylpencillin
  if highly penicillin and cephalosporin resistant, add vancomycin (+rifampicin if necessary)
• suggested duration 14 days

Question 11

treatment of meningitis caused by listeria (+ if hypersensitivity, plus durations)

Answer 11

Amox (or ampicillin) + gentamicin
21 days
Consider stopping gentamicin after 7 days
If Hx immediate hypersensitivity to penicillin, give co-trimoxazole
21 days

Question 12

treatment of meningitis caused by H influenza and duration of treatment, plus if HIb

Answer 12

Cefotaxime (or ceftriaxone)
Consider adjunct treatment with dexamethasone (as above)
Suggested duration of abx: 10 days
For Hib, give rifampicin 4 days before hospital discharge to <10 or those in contact with vulnerable household contacts
Vulnerable: <10, asplenia, immunosuppressed